BI24 A case of refractory pyoderma gangrenosum successfully treated with upadacitinib

Abstract A 44-year-old woman with a history of Crohn disease developed pyoderma gangrenosum (PG), which was resistant to multiple systemic treatments over 2 years. After she started upadacitinib, the PG ulcer healed within 6 months, supporting the potential of Janus kinase inhibitors in PG treatment. The patient also had enteropathic arthritis, initially controlled with infliximab and azathioprine. She was referred for a crusted plaque on her right shin, which evolved from a small papule over a year. Biopsy revealed acute inflammation consistent with folliculitis. However, the biopsy site did not heal and rapidly developed into a 2.5-cm painful ulcer clinically consistent with PG. Initial treatments were unsuccessful, including wound dressings, topical and systemic corticosteroids (intravenous methylprednisolone), topical tacrolimus and antibiotics. Ciclosporin was introduced when she did not respond to escalated doses of infliximab. Although there was initial improvement, renal function declined, and her blood pressure rose prompting a switch to upadacitinib as agreed with gastroenterology. The PG improved within 4 months, with reduction in pain and inflammatory markers. The ulcer fully healed after 6 months and her Crohn disease and enteropathic arthritis remained stable. Corticosteroids, ciclosporin and biologics remain the main systemic treatments for most PG. Case reports suggest upadacitinib is effective in treating PG with underlying inflammatory bowel disease and rheumatoid arthritis. This case highlights the importance of collaborating with other specialties regarding alternative treatments that are not available for dermatology conditions. Further studies are needed to evaluate the efficacy of Janus kinase inhibitors in PG.